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  H.B. No. 1696
 
 
 
 
AN ACT
  relating to the relationship between managed care plans and
  optometrists and therapeutic optometrists.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  The heading to Subchapter D, Chapter 1451,
  Insurance Code, is amended to read as follows:
  SUBCHAPTER D. ACCESS TO OPTOMETRISTS [AND OPHTHALMOLOGISTS] USED
  UNDER MANAGED CARE PLAN
         SECTION 2.  Section 1451.151, Insurance Code, is amended to
  read as follows:
         Sec. 1451.151.  DEFINITION [DEFINITIONS]. In this
  subchapter,[:
               [(1)]  "managed [Managed] care plan" means a plan under
  which a health maintenance organization, preferred provider
  benefit plan issuer, vision benefit plan issuer, vision benefit
  plan administrator, or other organization provides or arranges for
  health care benefits or vision benefits to plan participants and
  requires or encourages plan participants to use health care
  practitioners the plan designates.
               [(2)  "Ophthalmologist" means a physician who
  specializes in ophthalmology.]
         SECTION 3.  Section 1451.153, Insurance Code, is amended to
  read as follows:
         Sec. 1451.153.  USE OF OPTOMETRIST OR[,] THERAPEUTIC
  OPTOMETRIST[, OR OPHTHALMOLOGIST].  (a)  A managed care plan may
  not:
               (1)  discriminate against a health care practitioner
  because the practitioner is an optometrist or a[,] therapeutic
  optometrist[, or ophthalmologist];
               (2)  restrict or discourage a plan participant from
  obtaining covered vision or medical eye care services or procedures
  from a participating optometrist or[,] therapeutic optometrist[,
  or ophthalmologist] solely because the practitioner is an
  optometrist or[,] therapeutic optometrist[, or ophthalmologist];
               (3)  exclude an optometrist or a[,] therapeutic
  optometrist[, or ophthalmologist] as a participating practitioner
  in the plan because the optometrist or[,] therapeutic optometrist[,
  or ophthalmologist] does not have medical staff privileges at a
  hospital or at a particular hospital;
               (4)  identify a participating optometrist or
  therapeutic optometrist differently from another optometrist or
  therapeutic optometrist based on:
                     (A)  a discount or incentive offered on a medical
  or vision care product or service, as defined by Section 1451.155,
  that is not a covered product or service, as defined by Section
  1451.155, by the optometrist or therapeutic optometrist;
                     (B)  the dollar amount, volume amount, or percent
  usage amount of any product or good purchased by the optometrist or
  therapeutic optometrist; or
                     (C)  the brand, source, manufacturer, or supplier
  of a medical or vision care product or service, as defined by
  Section 1451.155, utilized by the optometrist or therapeutic
  optometrist to practice optometry;
               (5)  incentivize, recommend, encourage, persuade, or
  attempt to persuade an enrollee to obtain covered or uncovered
  products or services:
                     (A)  at any particular participating optometrist
  or therapeutic optometrist instead of another participating
  optometrist or therapeutic optometrist;
                     (B)  at a retail establishment owned by, partially
  owned by, contracted with, or otherwise affiliated with the managed
  care plan instead of a different participating optometrist or
  therapeutic optometrist; or
                     (C)  at any Internet or virtual provider or
  retailer owned by, partially owned by, contracted with, or
  otherwise affiliated with the managed care plan instead of a
  different participating optometrist or therapeutic optometrist;
               (6)  exclude an optometrist or a[,] therapeutic
  optometrist[, or ophthalmologist] as a participating practitioner
  in the plan because the services or procedures provided by the
  optometrist or[,] therapeutic optometrist[, or ophthalmologist]
  may be provided by another type of health care practitioner; or
               (7) [(5)]  as a condition for a therapeutic optometrist
  [or ophthalmologist] to be included in one or more of the plan's
  medical panels, require the therapeutic optometrist [or
  ophthalmologist] to be included in, or to accept the terms of
  payment under or for, a particular vision panel in which the
  therapeutic optometrist [or ophthalmologist] does not otherwise
  wish to be included.
         (b)  A managed care plan shall:
               (1)  include optometrists and[,] therapeutic
  optometrists[, and ophthalmologists] as participating health care
  practitioners in the plan; [and]
               (2)  include the name of a participating optometrist
  or[,] therapeutic optometrist[, or ophthalmologist] in any list of
  participating health care practitioners and give equal prominence
  to each name;
               (3)  provide directly to an optometrist, therapeutic
  optometrist, or plan enrollee immediate access by electronic means
  to an enrollee's complete plan coverage information, including
  in-network and out-of-network coverage details;
               (4)  publish complete plan information, including
  in-network and out-of-network coverage details, with any marketing
  materials that describe the plan benefits, including any summary
  plan description;
               (5)  allow an optometrist or a therapeutic optometrist
  to utilize any third-party claim-filing service, billing service,
  or electronic data interchange clearinghouse company that uses the
  standardized claim submission protocol of the National Uniform
  Claim Committee and that allows the optometrist or therapeutic
  optometrist to submit details for both services and vision care
  products to facilitate the authorization, submission, and
  reimbursement of claims; and
               (6)  allow an optometrist or a therapeutic optometrist
  to receive reimbursement through an electronic funds transfer.
         (c)  For the purposes of Subsection (a)(7) [(a)(5)],
  "medical panel" and "vision panel" have the meanings assigned by
  Section 1451.154(a).
         SECTION 4.  Section 1451.154(a)(2), Insurance Code, is
  amended to read as follows:
               (2)  "Vision panel" means the optometrists and[,]
  therapeutic optometrists[, and ophthalmologists] who are listed as
  participating providers for routine eye examinations under a
  managed care plan or who a patient seeking a routine eye examination
  is encouraged or required to use under a managed care plan.
         SECTION 5.  Section 1451.154(c), Insurance Code, is amended
  to read as follows:
         (c)  A therapeutic optometrist who is included in a managed
  care plan's medical panels under Subsection (b) must:
               (1)  abide by the terms and conditions of the managed
  care plan;
               (2)  satisfy the managed care plan's credentialing
  standards for therapeutic optometrists; and
               (3)  provide proof that the Texas Optometry Board
  considers the therapeutic optometrist's license to practice
  therapeutic optometry to be in good standing[; and
               [(4)  comply with the requirements of the Controlled
  Substances Registration Program operated by the Department of
  Public Safety].
         SECTION 6.  Section 1451.155, Insurance Code, is amended to
  read as follows:
         Sec. 1451.155.  CONTRACTS WITH OPTOMETRISTS OR THERAPEUTIC
  OPTOMETRISTS.  (a)  In this section:
               (1)  "Chargeback" means a dollar amount, fee,
  surcharge, or item of value that reduces, modifies, or offsets all
  or part of the patient responsibility, provider reimbursement, or
  fee schedule for a covered product or service.
               (2)  "Covered product or service" means a medical or
  vision care product or service for which reimbursement is available
  under an enrollee's managed care plan contract or for which
  reimbursement is available subject to a contractual limitation,
  including:
                     (A)  a deductible;
                     (B)  a copayment;
                     (C)  coinsurance;
                     (D)  a waiting period;
                     (E)  an annual or lifetime maximum limit;
                     (F)  a frequency limitation; or
                     (G)  an alternative benefit payment.
               (3) [(2)]  "Medical or vision [Vision] care product or
  service" means a product or service provided within the scope of the
  practice of optometry or therapeutic optometry under Chapter 351,
  Occupations Code.
         (a-1)  For the purposes of this section, a product or service
  reimbursed to an optometrist or therapeutic optometrist at a
  nominal or de minimis rate is not a covered product or service.
         (a-2)  For the purposes of this section, a product or service
  reimbursed to an optometrist or therapeutic optometrist solely by
  the enrollee is not a covered product or service.
         (b)  A contract between a managed care plan [an insurer] and
  an optometrist or therapeutic optometrist may not limit the fee the
  optometrist or therapeutic optometrist may charge for a product or
  service that is not a covered product or service.
         (c)  A contract between a managed care plan [an insurer] and
  an optometrist or therapeutic optometrist may not require a
  discount on a product or service that is not a covered product or
  service.
         (d)  A contract between a managed care plan and an
  optometrist or therapeutic optometrist may not contain a provision
  authorizing a chargeback to the patient, optometrist, or
  therapeutic optometrist if the chargeback is for a covered product
  or service that the managed care plan does not incur the cost to
  produce, deliver, or provide to the patient, optometrist, or
  therapeutic optometrist.
         (e)  A contract between a managed care plan and an
  optometrist or therapeutic optometrist may not contain a provision
  authorizing a reimbursement fee schedule for a covered product or
  service that is different from the fee schedule applicable to
  another optometrist or therapeutic optometrist because of the
  optometrist's or therapeutic optometrist's choice of:
               (1)  optical laboratory;
               (2)  source or supplier of:
                     (A)  contact lenses;
                     (B)  ophthalmic lenses;
                     (C)  ophthalmic glasses frames; or
                     (D)  covered or uncovered products or services;
               (3)  equipment used for patient care;
               (4)  retail optical affiliation;
               (5)  vision support organization;
               (6)  group purchasing organization;
               (7)  doctor alliance;
               (8)  professional trade association membership;
               (9)  affiliation with an arrangement defined as a
  franchise by 16 C.F.R. Part 436;
               (10)  electronic health record software, electronic
  medical record software, or practice management software; or
               (11)  third-party claim-filing service, billing
  service, or electronic data interchange clearinghouse company.
         (f)  A managed care plan may not change a contract between a
  managed care plan and an optometrist or therapeutic optometrist,
  including terms, reimbursements, or fee schedules, unless the
  managed care plan provides written notice of the change to the
  optometrist or therapeutic optometrist at least 90 days before the
  date the proposed change takes effect.
         (g)  A contract between a managed care plan and an
  optometrist or therapeutic optometrist may not contain a provision
  requiring the optometrist or therapeutic optometrist to provide a
  covered product at a loss.
         (h)  A contract between a managed care plan and an
  optometrist or therapeutic optometrist may not contain a provision
  requiring the optometrist or therapeutic optometrist to accept a
  reimbursement payment in the form of a virtual credit card or any
  other payment method where a processing fee, administrative fee,
  percentage amount, or dollar amount is assessed to receive the
  reimbursement payment, except in the case of a nominal fee assessed
  by the optometrist's or therapeutic optometrist's bank to receive
  an electronic funds transfer.
         SECTION 7.  The heading to Section 1451.156, Insurance Code,
  is amended to read as follows:
         Sec. 1451.156.  CERTAIN CONDUCT PROHIBITED [CONDUCT].
         SECTION 8.  Section 1451.156(a), Insurance Code, is amended
  to read as follows:
         (a)  A managed care plan, as described by Section
  1451.152(a), may not directly or indirectly:
               (1)  control or attempt to control the professional
  judgment, manner of practice, or practice of an optometrist or
  therapeutic optometrist;
               (2)  employ an optometrist or therapeutic optometrist
  to provide a vision care product or service as defined by Section
  1451.155;
               (3)  pay an optometrist or therapeutic optometrist for
  a service not provided;
               (4)  reimburse an optometrist or therapeutic
  optometrist a different amount for a covered product or service as
  defined by Section 1451.155 because of the optometrist's or
  therapeutic optometrist's choice of:
                     (A)  optical laboratory;
                     (B)  source or supplier of:
                           (i)  contact lenses;
                           (ii)  ophthalmic lenses;
                           (iii)  ophthalmic glasses frames; or
                           (iv)  covered or uncovered products or
  services;
                     (C)  equipment used for patient care;
                     (D)  retail optical affiliation;
                     (E)  vision support organization;
                     (F)  group purchasing organization;
                     (G)  doctor alliance;
                     (H)  professional trade association membership;
                     (I)  affiliation with an arrangement defined as a
  franchise by 16 C.F.R. Part 436;
                     (J)  electronic health record software,
  electronic medical record software, or practice management
  software; or
                     (K)  third-party claim-filing service, billing
  service, or electronic data interchange clearinghouse company;
               (5)  restrict, [or] limit, or influence an
  optometrist's or therapeutic optometrist's choice of sources or
  suppliers of services or materials, including optical laboratories
  used by the optometrist or therapeutic optometrist to provide
  services or materials to a patient;
               (6)  restrict, limit, or influence an optometrist's or
  therapeutic optometrist's choice of electronic health record
  software, electronic medical record software, or practice
  management software;
               (7)  restrict, limit, or influence an optometrist's or
  therapeutic optometrist's choice of third-party claim-filing
  service, billing service, or electronic data interchange
  clearinghouse company;
               (8)  restrict or limit an optometrist's or therapeutic
  optometrist's access to a patient's complete plan coverage
  information, including in-network and out-of-network coverage
  details;
               (9)  apply a chargeback, as defined by Section
  1451.155, to a patient, optometrist, or therapeutic optometrist if
  the chargeback is for a covered product or service that the managed
  care plan does not incur the cost to produce, deliver, or provide to
  the patient, optometrist, or therapeutic optometrist;
               (10)  require an optometrist or therapeutic
  optometrist to provide a covered product at a loss; [or]
               (11) [(5)]  require an optometrist or therapeutic
  optometrist to disclose a patient's confidential or protected
  health information unless the disclosure is authorized by the
  patient or permitted without authorization under the Health
  Insurance Portability and Accountability Act of 1996 (42 U.S.C.
  Section 1320d et seq.) or under Section 602.053;
               (12)  require an optometrist or therapeutic
  optometrist to disclose or report a medical history or diagnosis as
  a condition to file a claim, adjudicate a claim, or receive
  reimbursement for a routine or wellness vision eye exam;
               (13)  require an optometrist or therapeutic
  optometrist to disclose or report a patient's glasses prescription,
  contact lens prescription, ophthalmic device measurements, facial
  photograph, or unique anatomical measurements as a condition to
  file a claim, adjudicate a claim, or receive reimbursement for a
  claim unless the information is needed for the managed care plan to
  manufacture or cause to be manufactured a covered product that is
  submitted on the claim;
               (14)  require an optometrist or therapeutic
  optometrist to disclose any patient information, other than
  information identified on the version of the Health Insurance Claim
  Form approved by the National Uniform Claim Committee as of March 1,
  2023, as a condition to file a claim, adjudicate a claim, or receive
  reimbursement for a claim unless the information is needed for the
  managed care plan to manufacture or cause to be manufactured a
  covered product that is submitted on the claim; or
               (15)  require an optometrist or therapeutic
  optometrist to accept a reimbursement payment in the form of a
  virtual credit card or any other payment method where a processing
  fee, administrative fee, percentage amount, or dollar amount is
  assessed to receive the reimbursement payment, except in the case
  of a nominal fee assessed by the optometrist's or therapeutic
  optometrist's bank to receive an electronic funds transfer.
         SECTION 9.  Subchapter D, Chapter 1451, Insurance Code, is
  amended by adding Sections 1451.157 and 1451.158 to read as
  follows:
         Sec. 1451.157.  EXTRAPOLATION PROHIBITED. (a)  In this
  section:
               (1)  "Extrapolation" means a mathematical process or
  technique used by a vision care plan in the audit of an optometrist
  or therapeutic optometrist to estimate audit results or findings
  for a larger batch or group of claims not reviewed by the plan.
               (2)  "Vision care plan" means a limited-scope policy,
  agreement, contract, or evidence of coverage that provides coverage
  for eye care expenses but does not provide comprehensive medical
  coverage.
         (b)  A vision care plan may not use extrapolation to complete
  an audit of a participating optometrist or therapeutic optometrist.  
  Any additional payment due to a participating optometrist or
  therapeutic optometrist or any refund due to the vision care plan
  must be based on the actual overpayment or underpayment and may not
  be based on an extrapolation.
         Sec. 1451.158.  ENFORCEMENT OF SUBCHAPTER. (a)  A violation
  of this subchapter by a managed care plan is subject to an
  administrative penalty under Chapter 84.
         (b)  The commissioner shall take all reasonable actions to
  ensure compliance with this subchapter, including issuing orders to
  enforce this subchapter.
         SECTION 10.  Sections 1451.154(d) and 1451.156(d),
  Insurance Code, are repealed.
         SECTION 11.  The changes in law made by this Act apply only
  to a contract between a managed care plan or vision care plan and an
  optometrist or a therapeutic optometrist entered into or renewed,
  or a managed care plan or vision care plan delivered, issued for
  delivery, or renewed, on or after January 1, 2024.  A contract
  entered into or renewed, or a managed care plan or vision care plan
  delivered, issued for delivery, or renewed, before January 1, 2024,
  is governed by the law as it existed immediately before the
  effective date of this Act, and that law is continued in effect for
  that purpose.
         SECTION 12.  This Act takes effect September 1, 2023.
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
 
         I certify that H.B. No. 1696 was passed by the House on May 8,
  2023, by the following vote:  Yeas 143, Nays 0, 1 present, not
  voting.
 
  ______________________________
  Chief Clerk of the House   
 
 
         I certify that H.B. No. 1696 was passed by the Senate on May
  23, 2023, by the following vote:  Yeas 31, Nays 0.
 
  ______________________________
  Secretary of the Senate    
  APPROVED:  _____________________
                     Date          
   
            _____________________
                   Governor